MINISTRY OF HEALTH

DRUG REPORT FORM

The objective of the Drug Report Form is to capture information on adverse drug reaction as well as the efficacy of drugs.
The form is therefore intended as a tool for drug surveillance reporting. The information provided may be used to guide
the decision making process with respect to drug selection thereby ensuring that only the most effective therapies are used.

SECTION 1 - ADVERSE DRUG REACTION (ADR)

1.1 PATIENT INFORMATION

Patient Initials: Sex: M / F Weight (kg):

Age (at time of reaction) Identification (Your Practice/Hospital Ref.):

1.2 PATIENT MEDICAL HISTORY

1.3 SUSPECTED DRUG(S)

Give brand name of drug and

batch number if known Route Dosage Date Started Date Stopped Quantity taken
1.4 OTHER DRUGS (Including self medication and herbal remedies)

Did the patient take any other drugs in the last three months prior to the reaction? Yes / No
If yes, please give the following information if known:
Drug (Brand if known) Route Dosage Date started Date Stopped Prescribed for

1.5 TYPE OF REACTION(S) OBSERVED AND TREATMENT GIVEN

Allergy ( ) Severe Nausea ( ) Dizziness ( ) Bleeding ( ) Wheezing ( )

Other (please sepcify)
Onset of reaction after first dose: Within one hour ( ) six hours ( ) Twelve hours ( ) one day ( ) Other
(specify)
Date ADR ended
Severity of reaction: Mild ( ) Moderate ( ) Very Severe ( ) Hospitalization required ( ) Incapacitated ( )
Birth Defect ( ) Death ( )
Any previous reaction in same person?
Please state treatment given and outcome:
SECTION 2 - DRUG REVIEW
2.1 DRUG EFFICACY

Name of Drug Strength

Goal of therapy achieved Yes / No
Drug as effectrive as other brands Yes / No
Drug effective as others in same category Same ( ) More than ( ) Less than ( )
Drug recommended for continued use Yes / No

2.2 UNSATISFACTORY PHYSICAL FEATURES

Drug Packaging ( ) Labelling by Manufacturer ( ) Stability ( ) Breaking of tablets ( ) Colour change ( )

Other (specify)
Reason for response

Reported by:
Doctor ( ) Pharmacist ( ) Nurse ( ) Patient ( ) Other ( )
Name of Institution Name of Doctor (if not the reporter)
Address Address
Telephone
Signature Date

Return to : Standards and Regulation Division, Ministry of Health, 9th Floor, 2 - 4 King Street, Kingston, Jamaica, West Indies:
Tel: 967 -1100 - 3; Fax: 967 - 1629